A.Standard Definitions

1.Accident

means a sudden, unforeseen, and involuntary event caused by external, visible and violent means.

2.Cashless Facility

Cashless facility means a facility extended by the insurer to the insured where the payments, of the costs of treatment undergone by the insured in accordance with the policy terms and conditions, are directly made to the network provider by the insurer to the extent pre-authorization is approved.

3.Condition Precedent

shall mean a policy term or condition upon which the Insurer’s liability under the policy is conditional upon.

4.Congenital Anomaly

refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure, or position.

1. Internal Congenital Anomaly – Congenital anomaly which is not in the visible and accessible parts of the body.
2. External Congenital Anomaly – Congenital anomaly which is in the visible and accessible parts of the body.

5.Co-Payment

means a cost sharing requirement under a health insurance policy that provides that the Policyholder/ Insured will bear a specified percentage of the admissible claims amount. A co-payment does not reduce the Sum Insured.

6.Cumulative Bonus

means any increase or addition in the Sum Insured granted by the insurer without an associated increase in premium.

7.Day Care Centre

means any institution established for day care treatment of illness and/or injuries or a medical set-up within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under:

1. Has qualified nursing staff under its employment
2. Has qualified Medical Practitioner(s) in charge
3. Has a fully equipped operation theatre of its own where surgical procedures are carried out;
4. Maintains daily records of patients and will make these accessible to the Insurance Company’s authorized personnel.

8.Day Care Treatment

means medical treatment, and/or surgical procedure which is:

1. undertaken under general or local anesthesia in a hospital/day care Centre in less than twenty-four hours because of technological advancement, and
2. which would have otherwise required hospitalisation of more than twenty-four hours.

Treatment normally taken on an out-patient basis is not included in the scope of this definition

9.Dental Treatment               

means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions and surgery.

10.Emergency Care

means management for an illness or injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a medical practitioner to prevent death or serious long-term impairment of the Insured person’s health.

11.Grace Period

means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a policy in force without loss of continuity benefits such as waiting periods and coverage of pre-existing diseases. Coverage is not available for the period for which no premium is received.

12.Hospital

means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a Hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:

1. Has qualified nursing staff under its employment round the clock
2. Has at least 10 in-patient beds in towns having a population of less than 10 lacs and at least 15 in-patient beds in all other places;
3. Has qualified Medical Practitioner(s) in charge round the clock;
4. Has a fully equipped Operation Theatre of its own where surgical procedures are carried out;
5. Maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel

13.Hospitalisation

means admission in a Hospital for a minimum period of 24 Inpatient care consecutive hours except for the standard day care procedures/treatments as defined above, where such admission could be for a period of less than 24 consecutive hours.

14.Illness

means a sickness or a disease or pathological condition leading to the impairment of normal physiological function and requires medical treatment.

1. Acute Condition - Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease/ illness/ injury which leads to full recovery.
2. Chronic Condition – A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:
   • it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests
   • it needs ongoing or long-term control or relief of symptoms
   • it requires rehabilitation for the patient or for the patient to be specially trained to cope with it
   • it continues indefinitely
   • it recurs or is likely to recur.

15.Injury

means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent, visible and evident means which is verified and certified by a Medical Practitioner.

16.In-Patient Care

means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.

17.Intensive Care Unit

means an identified section, ward or wing of a hospital which is under the constant supervision of a dedicated Medical Practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.

18.Intensive Care Unit (ICU) Charges

means the amount charged by a Hospital towards ICU expenses which shall include the expenses for ICU bed, general medical support services provided to any ICU patient including monitoring devices, critical care nursing and intensivist charges.

19.Maternity Expenses means

1. medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization);
2. expenses towards lawful medical termination of pregnancy during the policy period.

20.Medical Advice

means any consultation or advice from a Medical Practitioner including the issuance of any prescription or follow-up prescription.

21.Medical Expenses

means those expenses that an Insured Person has necessarily and actually incurred for medical treatment on account of illness or Accident on the advice of a Medical Practitioner, as long as these are no more than would have been payable if the Insured Person had not been insured and no more than other hospitals or doctors in the same locality would have charged for the same medical treatment.

22.Medically Necessary Treatment

means any treatment, tests, medication, or stay in hospital or part of a stay in hospital which:

3. is required for the medical management of the illness or injury suffered by the Insured
4. must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;
5. must have been prescribed by a medical practitioner;
6. must conform to the professional standards widely accepted in international medical practice or by the medical community in India.

23.Medical Practitioner

means a person who holds a valid registration from the Medical Council of any State or Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within its scope and jurisdiction of license.

24.Migration

means the right accorded to health insurance policyholders (including all members under family cover and members of group health insurance policy), to transfer the credit gained for pre-existing conditions and time-bound exclusions, with the same insurer.

25.Network Provider

means hospitals or health care providers enlisted by an insurer, TPA or jointly by an Insurer and TPA to provide medical services to an insured by a cashless facility.

26.Non-Network Provider

means any hospital, day care centre or other provider that is not part of the network.

27.Notification Of Claim

means the process of intimating a claim to the insurer or TPA through any of the recognized modes of communication.

28.Out-Patient (OPD) Treatment

means the one in which the Insured visits a clinic / hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as a day care or in-patient.

29.Portability

means the right accorded to individual health insurance policyholders (including all members under family cover), to transfer the credit gained for pre-existing conditions and time-bound exclusions, from one insurer to another insurer.

30.Pre-Existing Disease

means any condition, ailment, injury or disease:

1. That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or
2. For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy or its reinstatement.

31.Pre-Hospitalisation Medical Expenses

means medical expenses incurred during pre-defined number of days preceding the hospitalization of the Insured Person, provided that:

1. Such Medical expenses are incurred for the same condition for which the Insured Person’s Hospitalisation was required

32.Post-Hospitalisation Medical Expenses

means medical expenses incurred during pre-defined number of days immediately after the insured person is discharged from the hospital provided that:

1. Such Medical expenses are incurred for the same condition for which the Insured Person’s Hospitalisation was required.

33.Qualified Nurse

means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.

34.Reasonable And Customary Charges

mean the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of illness/injury involved.

35.Renewal

means the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the renewal continuous for the purpose of gaining credit for pre-existing diseases, time-bound exclusions and for all waiting periods.

36.Room Rent

means the amount charged by a Hospital towards room and boarding expenses and shall include the Associated Medical Expenses.

37.Surgery Or Surgical Procedure

means manual and/or operative procedure(s) required for treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief from suffering and prolongation of life, performed in a hospital or day care centre by a medical practitioner.

38.Unproven/Experimental Treatment

means the treatment including drug experimental therapy which is not based on established medical practice in India, is treatment experimental or unproven.

B.Specific Definitions

1.Age

means completed age in years on the Policy Commencement Date.

2.Associated Medical Expenses

means hospitalisation-related expenses on Surgeon, Anesthetist, Medical Practitioner, Consultants and Specialist Fees (whether paid directly to the treating doctor/surgeon or hospital), Anesthetics, Blood, Oxygen, Operation Theatre charges, surgical appliances, and other similar expenses which vary based on the room category occupied by the Insured Person whilst undergoing treatment in a hospital. Associated Medical expenses do not include:

1. cost of pharmacy and consumables
2. cost of implants/medical devices
3. cost of diagnostics

The scope of this definition is limited to admissible claims where a proportionate deduction is applicable.

3.Break in policy

means the period of gap that occurs at the end of the existing policy term, when the premium due for renewal on a given policy is not paid on or before the premium renewal date or within 30 days thereof.

4.Cancellation

defines the terms on which the policy contract can be terminated either by the Insurer or the Insured person by giving sufficient notice to the other which is not lower than a period of fifteen days.

5.Continuous Coverage

means uninterrupted coverage of the Insured Person under the Health Insurance Policy from the date of inception of the policy for the first time as mentioned in the policy schedule. However, for the purpose of applying waiting periods, the break in insurance period for which the premium was not received shall be excluded from it.

6.Family

means the Insured persons named in the Policy Schedule.

7.Insured Person

means person(s) named in the schedule of the Policy.

8.Material Fact

means all relevant information sought by the Company in the Proposal Form and other connected documents to enable it to take an informed decision in the context of underwriting the risk.

9.Nominee

means the person named in the Policy Schedule, Policy certificate and/or endorsement (if any) who is nominated by the Policy Holder/Insured Person, to receive the benefits under this Policy as per the terms of the Policy if the Insured Person deceases.

10.Organ Donor

means any person whose organ has been made available in accordance and compliance with The Transplantation of Human Organs (Amendment) Act, 1994 and relevant rules and amendments thereof. The organ donated must be for the use of the Insured Person.

11.Policy

means these Policy wordings, the Policy Schedule and any applicable endorsements or extensions attaching to and/or forming part thereof. The Policy contains details of the benefits, exclusions, and applicable terms & conditions.

12.Policy Period

means the period for which this policy is taken and is in force as specified in the Schedule.

13.Preferred Provider Network (PPN)

means a network of hospitals which have agreed to a cashless packaged pricing for certain procedures for the Insured Person. The updated list of network providers/PPN is available on our website (https://uiic.co.in/en/tpa-ppn-network-hospitals) and the website of the TPA mentioned in the schedule and is subject to amendments.

14.Proposal Form

means the form to be filled in by the prospect in written or electronic or any other format as requested by the Company and approved by the IRDAI, for furnishing all material information as required by the Insurer, to:

1. Enable the Insurer to take an informed decision in the context of underwriting the risk
2. And in the event of acceptance of the risk, to determine the rates, benefits, terms and conditions of the cover to be granted.

15.Shared Accommodation

means a twin-sharing room. This room may have an attached washroom, television, telephone, and couch. Such room must be the most economical of all such accommodations available in that hospital as twin-sharing occupancy. This does not include single private room / suite or room with additional facilities other than those stated herein. However, admission to any type of multi-bed ward including general ward will be considered within the ambit of this definition.

16.Sub-Limit

means a cost sharing requirement under a health insurance policy in which an Insurer would not be liable to pay any amount in excess of the pre-defined limit.

17.Sum Insured

means the pre-defined limit specified in the Policy Schedule. Sum Insured and Cumulative Bonus represents the maximum, total and cumulative liability for any and all claims made under the Policy, in respect of that Insured Person (on Individual basis) or all Insured Persons (on Floater basis) during the Policy Year.

18.Third-Party Administrator (TPA)

means a company registered under the IRDAI (Third Party Administrators – Health Services) Regulations, 2016 notified by the Authority, and is engaged, for a fee or remuneration by an insurance company, for the purpose of providing health services as defined in the regulations.

19.Waiting Period

means a period from the inception of this Policy during which specified diseases/treatments are not covered. On completion of the period, diseases/treatments shall be covered provided the Policy has been continuously renewed without any break.

20.We/Our/Us/Company/Insurer

means United India Insurance Company Limited

21.You/Your

means the person who has taken this Policy and is shown as Insured Person or the first Insured Person (if more than one person covered in the policy) in the Schedule.

A.Base Covers

The Policy provides base coverage as described below in this section provided that the expenses are incurred on the written Medical Advice of a Medical Practitioner and are incurred on Medically Necessary Treatment of the Insured Person.

1.In-patient Hospitalisation Expenses Cover

We will pay the Reasonable and Customary Charges for the following Medical Expenses taken during Hospitalisation provided that the admission date of the Hospitalisation due to Illness or Injury is within the Policy Period:

1. Room Rent (for Shared Accommodation), Boarding and Nursing expenses incurred as provided by the Hospital. These expenses will include nursing care, RMO charges, patient’s diet charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses.
2. Charges for accommodation in Intensive Care Unit (ICU)/ Intensive Cardiac Care Unit (ICCU).
3. The fees charged by the Medical Practitioner, Surgeon, Specialists, and anaesthetists treating the Insured Person;
4. Operation Theatre charges,
5. Anaesthesia, Blood, Oxygen, Surgical Appliances and/ or Medical Appliances, medicines and drugs, Cost of Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like pacemaker, orthopaedic implants, infra cardiac valve replacements, vascular stents, relevant laboratory/ diagnostic tests, X-Ray, dialysis, chemotherapy, radiotherapy, and such other associated expenses related to the treatment.

1.1 Note:

1. PROPORTIONATE PAYMENT CLAUSE: In case of admission to a room other than Shared Accommodation, the reimbursement/payment of all associated medical expenses incurred at the Hospital shall be effected in the same proportion as the admissible rate per day bears to the actual rate per day of Room Rent.

Proportionate Deductions shall not be applied in respect of those hospitals where differential billing is not followed or for those expenses where differential billing is not adopted based on the room category.

2. No payment shall be made under clause 8.A.1.iii other than as part of the hospitalisation bill. However, the bills raised by Surgeon, Anaesthetist directly and not forming part of the hospital bill shall be paid provided a pre-numbered bill/receipt is produced in support thereof, when such payment is made ONLY by cheque/credit card/debit card or digital/online transfer.
3. All Day Care treatments as defined in the policy are covered.

2.Pre-Hospitalisation and Post-Hospitalisation Expenses –

We will cover, on a reimbursement basis, the Insured Person’s

1. Pre-hospitalisation Medical Expenses incurred due to an Illness or Injury during the period up to 60 days prior to hospitalisation; and
2. Post- hospitalisation Medical Expenses incurred due to an Illness or Injury during the period up to 90 days after the discharge from the hospital.

Conditions:

1. The Pre-hospitalisation and Post-hospitalisation Medical Expenses are related to the same Illness or Injury.

3.Organ Donor Expenses Cover

We will cover the In-patient Hospitalization Medical Expenses incurred for an organ donor’s treatment during the Policy Period for the harvesting of the organ donated provided that:

1. The donation conforms to The Transplantation of Human Organs Act 1994 and the organ is for the use of the Insured Person;
2. We have admitted a claim towards In-patient Hospitalisation under Clause 8.A.1 and it is related to the same condition; organ donated is for the use of the Insured Person as certified in writing by a Medical Practitioner;
3. We will not cover:
   • Pre-hospitalization Medical Expenses or Post-hospitalisation Medical Expenses of the organ donor;
   • Screening expenses of the organ donor;
   • Costs directly or indirectly associated with the acquisition of the donor’s organ;
   • Transplant of any organ/tissue where the transplant is experimental or investigational;
   • Expenses related to organ transportation or preservation;
   • Any other medical treatment or complication in respect of the donor, consequent to harvesting.

4.Modern Treatment Methods & Advancement in Technologies:

In case of an admissible claim under Clause 8.A.1, expenses incurred on the following procedures (wherever medically indicated) shall be covered:

1. Uterine Artery Embolization and HIFU (High Intensity focused ultrasound)
2. Balloon Sinuplasty
3. Deep Brain Stimulation
4. Oral Chemotherapy
5. Immunotherapy - Monoclonal Antibody to be given as an injection
6. Intra-vitreal injections
7. Robotic Surgeries
8. Stereotactic Radio Surgeries
9. Bronchial Thermoplasty
10. Vaporization of the Prostrate (Green Laser Treatment or Holmium Laser Treatment)
11. IONM - (Intra Operative Neuro Monitoring)
12. Stem Cell Therapy; Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered

5.Cumulative Bonus (CB)

The insured person(s) shall be rewarded Cumulative Bonus calculated at 50% of the Sum Insured as bonus for each claim free year subject to a maximum of 100% of the Sum Insured. If a claim is made in any particular year, the cumulative bonus accrued shall be reduced at the same rate at which it has accrued.

Note:

1. The CB shall be withdrawn if the policy is not renewed within Grace Period.
2. In case where the policy is on individual basis, the CB shall be available individually to each insured person. CB shall reduce only in case of claim from the same Insured Person. In case where the policy is on floater basis, the CB shall be available to the family on floater basis, provided no claim has been reported from any member of the family. CB shall reduce in case of claim from any of the Insured Persons.
3. If the Insured Persons in the expiring policy are covered on an individual basis as specified in the Policy Schedule and there is an accumulated CB for such Insured Person under the expiring policy, and such expiring policy has been renewed on a floater policy basis as specified in the Policy Schedule then the CB to be carried forward for credit in such Renewed Policy shall be the one that is applicable to the lowest among all the Insured Persons.
4. In case of floater policies where Insured Persons renew their expiring policy by splitting the Sum Insured into two or more floater policies/individual policies, the CB of expiring policy shall be apportioned to such renewed Policies in the proportion of the Sum Insured of each renewed Policy.
5. If the Sum Insured has been reduced at the time of renewal, the applicable CB shall be reduced in the same proportion to the Sum Insured in current Policy.
6. If the Sum Insured under the Policy has been increased at the time of Renewal the CB shall be calculated on the Sum Insured of the last completed Policy Year.
7. If a claim is made in the expiring Policy Year, and is notified to Us after the acceptance of Renewal premium any awarded CB shall be withdrawn.

6.Road Ambulance Cover

We will cover the costs incurred on transportation of the Insured Person by road Ambulance to a Hospital for treatment in an Emergency following an Illness or Injury which occurs during the Policy Period. The necessity of use of an Ambulance must be certified by the treating Medical Practitioner and becomes payable if a claim has been admitted under Clause 8.A.1 and the expenses are related to the same Illness or Injury.

We will also cover the costs incurred on transportation of the Insured Person by road Ambulance in the following circumstances under this cover, if:   

1. it is medically required to transfer the Insured Person to another Hospital or diagnostic Centre during the course of Hospitalization for advanced diagnostic treatment in circumstances where such facility is not available in the existing Hospital;
2. it is medically required to transfer the Insured Person to another Hospital during the course of Hospitalization due to lack of super specialty treatment in the existing Hospital.

B.Optional Cover:

1.Waiver of Co-payment

If this cover is opted, then the applicable Co-Payment will be waived off, subject to payment of premium for Zone A.

1.Notification of Claim

Upon the happening of any event which may give rise to a claim under this Policy, the Insured Person/Insured Person’s representative shall notify the TPA (if claim is processed by TPA)/company (if claim is processed by the company) in writing providing all relevant information relating to claim including plan of treatment, policy number etc. within the prescribed time limit as under:

1. Within 24 hours from the date of emergency hospitalisation required or before the Insured Person’s discharge from Hospital, whichever is earlier.
2. At least 48 hours prior to admission in Hospital in case of a planned Hospitalisation

2.Procedure for Cashless Claims

1. Cashless facility for treatment in network hospitals only shall be available to Insured if opted for claim processing by TPA.
2. Treatment may be taken in a network provider/PPN hospital and is subject to pre authorization by the TPA. Booklet containing list of network provider/PPN hospitals shall be provided by the TPA. Updated list of network provider/PPN is available on website of the company (https://uiic.co.in/en/tpa-ppn-network-hospitals) and the TPA mentioned in the schedule.
3. The customer may call the TPA’s toll free phone number provided in the policy copy/on the health ID card for intimation of claim and related assistance. Please keep the ID number handy for easy reference.
4. On admission in the network provider/PPN hospital, please produce the ID card issued by the TPA at the Hospital Helpdesk. Cashless request form available with the network provider/PPN and TPA shall be filled and submitted to the TPA for authorization.
5. The TPA upon getting cashless request form and related medical information from the Insured Person/ network provider/PPN shall issue pre-authorization letter to the hospital after verification.
6. At the time of discharge, the Insured Person shall verify and sign the discharge papers and pay for non-medical and inadmissible expenses.
7. The TPA reserves the right to deny pre-authorization in case the Insured Person is unable to provide the relevant medical details.
8. Denial of a Pre-authorization request is in no way to be construed as denial of treatment or denial of coverage. The Insured Person may get the treatment as per treating doctor’s advice and submit the claim documents to the TPA for possible reimbursement

3.Procedure for reimbursement of Claims

1. In non-network hospitals payment must be made up-front and for reimbursement of claims the Insured Person may submit the necessary documents to TPA (if claim is processed by TPA)/company (if claim is processed by the company) within the prescribed time limit.
2. Claims for Pre- and Post-Hospitalisation will be settled on reimbursement basis on production of relevant claim papers and cash receipts within the prescribed time limit.

4.Documents

The claim is to be supported with the following original documents and submitted within the prescribed time limit:

1. Duly completed claim form
2. Attending medical practitioner’s / surgeon’s certificate regarding diagnosis/ nature of operation performed along with date of diagnosis, advise for admission, investigation test reports etc. supported by the prescription from attending medical practitioner.
3. Medical history of the patient as recorded, bills (including break up of charges) and payment receipts duly supported by the prescription from attending medical practitioner/ hospital.
4. Discharge certificate/ summary from the hospital.
5. Cash-memos from the Diagnostic Centre(s)/ hospital(s)/ chemist(s) supported by proper prescription.
6. Payment receipts from doctors, surgeons and anaesthetists.
7. Bills, receipts, Stickers of the Implants.
8. Any other document required by company/ TPA

Note: In the event of a claim lodged as per Settlement under multiple policies clause and the original documents having been submitted to the other Insurer, the company may accept the duly certified documents listed under Clause 21.4 of the policy wordings and claim settlement advice duly certified by the other Insurer subject to satisfaction of the company.

5.Time Limit for submission of documents

Notes:

1. The company shall only accept bills/invoices/medical treatment related documents only in the Insured Person’s name for whom the claim is submitted.
2. Waiver of clause 21.5 of the policy wordings may be considered in extreme cases of hardship where it is proved to the satisfaction of the Company that under the circumstances in which the Insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time-limit.
3. The Insured Person shall also give the TPA / Company such additional information and assistance as the TPA / Company may require in dealing with the claim including an authorisation to obtain Medical and other records from the hospital, lab, etc.
4. All the documents submitted to TPA shall be electronically collected by us for settlement/denial of the claims by the appropriate authority.
5. Any medical practitioner or Authorised Person authorised by the TPA / Company shall be allowed to examine the Insured Person in case of any alleged injury or disease leading to Hospitalisation if so required.

6.Services offered by TPA

Servicing of claims i.e. claim admissions and assessments, under this Policy by way of preauthorization of cashless treatment or processing of claims, as per the terms and conditions of the policy.

The services offered by a TPA shall not include:

1. Claim settlement and claim rejection;
2. Any services directly to any Insured Person or to any other person unless such service is in accordance with the terms and conditions of the Agreement entered into with the Company.

1. Waiting Periods

The Company shall not be liable to make any payment under the policy in connection with or in respect of the following expenses till the expiry of waiting period mentioned below:

1. Pre-Existing Diseases (Code – Excl01)
   • Expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 12 months of continuous coverage after the date of inception of the first policy with us.
   • In case of enhancement of the Sum Insured, the exclusion shall apply afresh to the extent of the Sum Insured increase.
   • If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then the waiting period for the same would be reduced to the extent of prior coverage.
   • Coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by us.

2. Specified Disease/Procedure Waiting Period (Code – Excl02)
   • Expenses related to the treatment of the listed Conditions, surgeries/treatments as per Table A and Table B below, shall be excluded until the expiry of 12 months and 48 months respectively of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an accident.
   • In case of enhancement of the sum insured the exclusion shall apply afresh to the extent of the sum insured increase
   • If any of the specified disease/procedure falls under the waiting period specified for Pre-Existing diseases, then the longer of the two waiting periods shall apply
   • The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.
   • If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then the waiting period for the same would be reduced to the extent of prior coverage.
   • List of specific diseases/procedures:
     • Benign ENT disorders/ Acid peptic disease/ Benign skin disorders/cataract.
     • Calculus (stone) Diseases of Gall Bladder including Cholecystectomy
     • All types of Surgery for Hernia /Hydrocele
     • Calculus of the Urinary system (Kidney Stone/Urinary Bladder/Ureteric Stone)
     • Fissure / Fistula / Hemorrhoids/Pilonidal sinus/ varicose veins
     •  Gout/ Rheumatism/ Non infective arthritis
     • Spinal diseases unless arising from accident
     • Poly cystic ovarian disease/ Menorrhagia/ Fibromyoma/Hysterectomy
     • Internal congenital anomaly
     •  All internal and external benign tumors, cysts, polyps of any kind, including benign breast lumps.
     • Mental illness- Schizophrenia, Bipolar affective disorder, Depression, Obsessive compulsive disorder, Psychosis

3. 30-Day Waiting Period (Code – Excl03)

i. Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered.

ii. This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.

iii. The within-referred waiting period is made applicable to the enhanced sum insured in the event of granting a higher sum insured subsequently.

2. Standard Permanent Exclusions

The Company shall not be liable to make any payment under this Policy in respect of any expenses incurred by You in connection with or in respect of:

4. Investigation & Evaluation (Code – Excl04)
   • Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
   • Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.

Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:

5. Rest Cure, Rehabilitation and Respite Care (Code – Excl05)
   • Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, and moving around either by skilled nurses or assistants or non-skilled persons
   • Any services for people who are terminally ill to address physical, social, emotional and spiritual needs

Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:

6. Obesity/Weight Control (Code – Excl06)
   • Surgery to be conducted is upon the advice of the Doctor
   • The surgery/Procedure conducted should be supported by clinical protocols
   • The member has to be 18 years of age or older and
   • Body Mass Index (BMI):
     • Greater than or equal to 40 or
     • . greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight loss
     • Obesity-related cardiomyopathy
     • Coronary heart disease
     • Severe Sleep Apnea
     • Uncontrolled Type2 Diabetes

7. Change-of-Gender treatments (Code – Excl07)

Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.

8. Cosmetic or Plastic Surgery (Code – Excl08)

Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.

9. Hazardous or Adventure Sports (Code – Excl09)

Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.

10. Breach of Law (Code – Excl10)

Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.

11. Excluded Providers (Code – Excl11)

Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed on its website/notified to the policyholders are not admissible. However, in case of life-threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim.

12. (Code – Excl12)

Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.

13. (Code – Excl13)

Treatments received in health hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons.

14. (Code – Excl14)

Dietary supplements and substances that can be purchased without a prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of a hospitalisation claim or day care procedure.

15. Refractive Error (Code – Excl15)

Expenses related to the treatment for correction of eyesight due to refractive error less than 7.5 dioptres.

16. Unproven Treatments (Code – Excl16)

Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.

Expenses related to sterility and infertility. This includes:

17. Sterility and Infertility (Code – Excl17)
    • Any type of contraception, sterilization
    •  Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
    • Gestational Surrogacy
    • Reversal of sterilization

18. Maternity (Code- Excl18)
    • Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalisation) except ectopic pregnancy;
    • Expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period

3. Specific Permanent Exclusions

1. All expenses caused by or arising from or attributable to foreign invasion, act of foreign enemies, hostilities, warlike operations (whether war be declared or not or while performing duties in the armed forces of any country), civil war, public defence, rebellion, revolution, insurrection, military or usurped power.
2. All Illnesses/expenses caused by ionizing radiation or contamination by radioactivity from any nuclear fuel (explosive or hazardous form) or any nuclear waste from the combustion of nuclear fuel, nuclear/chemical/biological attack.
3.  Any expenses incurred on Domiciliary Hospitalization.
4. Any expenses incurred on Out-patient treatment (OPD treatment). Procedures/treatments usually done in outpatient department are not payable under the policy even if admitted/converted as an in-patient in the hospital for more than 24 hours.
5. . Any item(s) or treatment specified in ‘List of Non-Medical Expenses under this Policy’ as per clauses in Annexure – 1, unless specifically covered under the Policy.
6. Any treatment related to sleep disorder or sleep apnoea syndrome.
7.  Artificial life maintenance including life support machine use, from the date of confirmation by the treating doctor that the patient is in a vegetative state.
8. Change of treatment from one system of medicine to another system unless recommended by the consultant/hospital under whom the treatment is taken.
9. Circumcision unless necessary for Treatment of an Illness or Injury not excluded hereunder or due to an Accident.
10.  Congenital External Diseases or Defects or anomalies.
11. Cost of hearing aids; including optometric therapy.
12. Cost of routine medical examination and preventive health check-up unless as provided for in clause III.A.8.
13. Dental treatment or  surgery  of  any  kind  unless  necessitated  by  disease  or  accident  and  requiring hospitalisation.
14.  Intentional self-inflicted Injury or attempted suicide.
15.  Routine eye-examination expenses, cost of spectacles, contact lenses.
16. Stem cell implantation/Surgery/Therapy, harvesting, storage or any kind of treatment using stem cells except Hematopoietic stem cells for bone marrow transplant for haematological conditions; growth hormone therapy.
17. Treatments including Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy, chondrocyte or osteocyte implantation, procedures using platelet rich plasma, Trans Cutaneous Electric Nerve Stimulation; Use of oral immunomodulatory/ supplemental drugs.
18. Treatments other than Allopathy and AYUSH
19. Unless used intra-operatively, any expenses incurred on prosthesis, corrective devices; External and or durable Medical/ Non-medical equipment of any kind used for diagnosis and/or treatment and/or monitoring and/or maintenance and/or support including instruments used in treatment of sleep apnoea syndrome; Infusion pump, Oxygen concentrator, Ambulatory devices, sub cutaneous insulin pump and also any medical equipment, which are subsequently used at home. This is indicative. Please refer to clauses in Annexure-1 for the complete list of non-payable items.
20. Vaccination or inoculation of any kind unless it is post animal bite.
21.  In respect of the existing diseases, disclosed by the insured and mentioned in the policy schedule (based on insured’s consent), Insured Person is not entitled to get the coverage for specified ICD Codes

Benefit/Premium Illustration

Please note:

1. Premium rates specified in the illustrations below are standard premium rates exclusive of any loadings and GST.
2. Rates shown below are for Zone A of Yuvaan Health Insurance Policy.

ILLUSTRATIONS

Illustration 1: Self, Spouse and 2 Dependent Children